Healthcare Provider Details

I. General information

NPI: 1326372301
Provider Name (Legal Business Name): STATE OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BRADY CIR 2
SAINT LOUIS MO
63114-1110
US

IV. Provider business mailing address

11 BRADY CIR 2
SAINT LOUIS MO
63114-1110
US

V. Phone/Fax

Practice location:
  • Phone: 314-340-6701
  • Fax: 314-340-6746
Mailing address:
  • Phone: 314-340-6701
  • Fax: 314-340-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberE650S000001
License Number StateMO

VIII. Authorized Official

Name: MOLLY JANE BOECKMANN
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 573-751-4055